Inspection·August 27, 2025

F 0621 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). A suitable facility has been found, all necessary arrangements have been made, and the patient will be discharged .During an interview on 8/27/25 at 9:28 a.m. with the admission Services Manager (ASM), the ASM stated when the facility received a referral for admission, the admission staff reviewed the referral to ensure the facility could provide the services required. The ASM stated the admission staff would verify the residents' primary insurance, secondary insurance and copay. The ASM stated a three midnight stay at a general acute care hospital with an inpatient status was required for Medicare to cover skilled nursing services (medical and therapeutic services that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). The ASM stated Medicare would not cover skilled nursing services if there was no record of the three midnight stay at a general acute care hospital. During an interview on 8/27/25 at 9:45 a.m. with the BOM, the BOM stated when the facility received a referral for admission, the referral was reviewed to verify payment source. If a resident had no payment source, the resident was given a private option to pay. The BOM stated the admission staff would interview the resident or the resident's family member to agree on a payment plan. The BOM stated she spoke to the SW on 8/5/25 regarding the referral. The BOM stated she explained the three midnight stay qualifying requirement for Medicare coverage to the SW. The BOM stated since [Hospital A] did not bill Medicare for the three midnight stay requirement, Medicare will not cover services provided at the facility. The BOM stated she requested Resident 1's admission classification (status) to support services provided at [Hospital A] but the SW did not provide the information, therefore, the facility was unable to admit Resident 1. During a concurrent interview and record review on 8/27/25 at 10:45 a.m. with the BOM, the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016 was reviewed. The P&P indicated, . The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. The BOM stated admission was not based on payment source. The BOM stated the facility should have offered Resident 1 with a letter of agreement (LOA - a legally binding admission contract that outlines the terms of residency, services, and financial obligations). The BOM stated she should have followed through with the SW and Resident 1 should have been admitted . During an interview on 8/27/25 at 11:10 a.m. with the Director of Nursing (DON), the DON stated during the referral process, admission staff would consult with nursing staff to ensure the facility could provide the clinical service the resident required. The DON stated the facility could not deny admission based on the payment source. The DON stated Resident 1 should have been admitted .During an interview on 8/27/25 at 11:15 a.m. with the Administrator (ADM), the ADM stated the facility should admit the resident if the facility could provide the services the resident required. The ADM stated there was a missed opportunity to admit Resident 1 due to miscommunication between the BOM and the SW. The ADM stated the BOM did not know the referral was made from a VA general acute care hospital. The ADM stated the BOM should have clarified the required information with the SW. The ADM stated the facility should have admitted Resident 1 based on a LOA. The ADM stated admission was not based on the payment source. During a review of the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016, the P&P indicated, Purpose: To provide uniform guidelines for admission, transfer, discharge and bed-holds in compliance with state and federal guidelines. To promote equal access to quality care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Gardens Nursing and Rehabilitation Center 577 S. Peach Ave. Fresno, CA 93727 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0621 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facilitate continuity with care transitions. Policy: The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. admission: .The facility does not request or require residents or potential residents to waive their rights to Medicare or Medicaid (a joint federal and state health insurance program that provides free or low-cost health coverage to low-income U.S. citizens and permanent legal residents), nor does it request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for Medicare or Medicaid benefits. The facility does not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility; however, the facility does require a resident representative who has legal access to the resident's income or available resources to sign a contract of assurance (without incurring personal financial liability), for payment from the resident's income or resources. Event ID: Facility ID: 056207 If continuation sheet Page 3 of 3